Matthew J. Carty

Three Patients with Full Facial Transplantation

Unlike conventional reconstruction, facial transplantation seeks to correct severe deformities in a single operation. We report on three patients who received full-face transplants at our institution in 2011 in operations that aimed for functional restoration by coaptation of all main available motor and sensory nerves. We enumerate the technical challenges and postoperative complications and their management, including single episodes of acute rejection in two patients. At 6 months of follow-up, all facial allografts were surviving, facial appearance and function were improved, and glucocorticoids were successfully withdrawn in all patients.

Breast Implant–Associated Anaplastic Large-Cell Lymphoma: Long-Term Follow-Up of 60 Patients

PURPOSE Breast implant-associated anaplastic large-cell lymphoma (ALCL) is a recently described clinicopathologic entity that usually presents as an effusion-associated fibrous capsule surrounding an implant. Less frequently, it presents as a mass. The natural history of this disease and long-term outcomes are unknown. PATIENTS AND METHODS We reviewed the literature for all published cases of breast implant-associated ALCL from 1997 to December 2012 and contacted corresponding authors to update clinical follow-up. RESULTS The median overall survival (OS) for 60 patients was 12 years (median follow-up, 2 years; range, 0-14 years). Capsulectomy and implant removal was performed on 56 of 60 patients (93%). Therapeutic data were available for 55 patients: 39 patients (78%) received systemic chemotherapy, and of the 16 patients (28%) who did not receive chemotherapy, 12 patients opted for watchful waiting and four patients received radiation therapy alone. Thirty-nine (93%) of 42 patients with disease confined by the fibrous capsule achieved complete remission, compared with complete remission in 13 (72%) of 18 patients with a tumor mass. Patients with a breast mass had worse OS and progression-free survival (PFS; P = .052 and P = .03, respectively). The OS or PFS were similar between patients who received and did not receive chemotherapy (P = .44 and P = .28, respectively). CONCLUSION Most patients with breast implant-associated ALCL who had disease confined within the fibrous capsule achieved complete remission. Proper management for these patients may be limited to capsulectomy and implant removal. Patients who present with a mass have a more aggressive clinical course that may be fatal, justifying cytotoxic chemotherapy in addition to removal of implants.

A patient death attributable to implant-related primary anaplastic large cell lymphoma of the breast.

Summary: Implant-related primary anaplastic large cell lymphoma (ALCL) of the breast is a rare clinical entity. With increasing attention being paid to this disease, most cases reported to date in the literature have demonstrated indolent clinical courses responsive to explantation, capsulectomy, chemotherapy, and/or radiotherapy. The authors describe a case of bilateral implant-related primary ALCL of the breast that proved refractory to both standard and aggressive interventions, ultimately resulting in patient death secondary to disease progression. The authors situate this case in the context of the current state of knowledge regarding implant-related primary ALCL of the breast and suggest that this entity is generally, but not universally, indolent in nature. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, V.

A detailed analysis of the reduction mammaplasty learning curve: a statistical process model for approaching surgical performance improvement.

Background: The increased focus on quality and efficiency improvement within academic surgery has met with variable success among plastic surgeons. Traditional surgical performance metrics, such as morbidity and mortality, are insufficient to improve the majority of today’s plastic surgical procedures. In-process analyses that allow rapid feedback to the surgeon based on surrogate markers may provide a powerful method for quality improvement. Methods: The authors reviewed performance data from all bilateral reduction mammaplasties performed at their institution by eight surgeons between 1995 and 2007. Multiple linear regression analyses were conducted to determine the relative impact of key factors on operative time. Explanatory learning curve models were generated, and complication data were analyzed to elucidate clinical outcomes and trends. Results: A total of 1068 procedures were analyzed. The mean operative time for bilateral reduction mammaplasty was 134 ± 34 minutes, with a mean operative experience of 11 ± 4.7 years and total resection volume of 1680 ± 930 g. Multiple linear regression analyses showed that operative time (R = 0.57) was most closely related to surgeon experience and resection volume. The complication rate diminished in a logarithmic fashion with increasing surgeon experience and in a linear fashion with declining operative time. Conclusions: The results of this study suggest a three-phase learning curve in which complication rates, variance in operative time, and operative time all decrease with surgeon experience. In-process statistical analyses may represent the beginning of a new paradigm in academic surgical quality and efficiency improvement in low-risk surgical procedures.

The influence of volume and experience on individual surgical performance: a systematic review.

OBJECTIVE To systematically review studies evaluating the influence of surgical experience on individual performance. BACKGROUND Experience, measured in case volume or years of practice, is recognized as a key driver of individual surgical performance, giving rise to a learning curve. However, this topic has not been reviewed at the cross-specialty level. METHODS MEDLINE, EMBASE, PsycINFO, AMED, and the Cochrane Database of Systematic Reviews were searched (from inception to February 2013). Two reviewers independently reviewed citations using predetermined inclusion and exclusion criteria. Ninety-one data points per study were extracted. RESULTS The search strategy yielded 6950 citations. Fifty-seven studies were eligible, including 1,061,913 cases and 35 procedure types, performed by 17,912 surgeons. Forty-five studies monitored case volume, and 6 studies measured experience as both case volume and years of practice. Of these 51 studies, 44 found that increased case volume was associated with significantly improved health outcomes. Several studies noted a plateau phase or maturation in the surgical learning curve. Acquisition of this phase was procedure specific and outcome specific, ranging from 25 to 750 procedures. Twelve studies assessed the impact of years of surgical practice, 11 of which found that increased years of experience was associated with significantly improved health outcomes. Two studies noted a plateau phase, where increases in years of experience were no longer associated with improvements in operative outcomes. Three studies identified performance deterioration after the plateau phase. CONCLUSIONS Increasing surgical case volume and years of practice are associated with improved performance, in a procedure-specific manner. Performance may deteriorate toward the end of a surgeons career.

Lessons learned from simultaneous face and bilateral hand allotransplantation.

Summary: The performance of simultaneous vascularized composite allotransplantation procedures on patients requiring both the face and bilateral hands remains controversial. The authors present their separate institutional experiences with this challenging procedure in the interests of dispelling misconceptions regarding this intervention and forwarding their understanding of the issues related to concomitant vascularized composite allotransplantation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Cumulative team experience matters more than individual surgeon experience in cardiac surgery.

OBJECTIVES Individual surgeon experience and the cumulative experience of the surgical team have both been implicated as factors that influence surgical efficiency. We sought to quantitatively evaluate the effects of both individual surgeon experience and the cumulative experience of attending surgeon-cardiothoracic fellow collaborations in isolated coronary artery bypass graft (CABG) procedures. METHODS Using a prospectively collected retrospective database, we analyzed all medical records of patients undergoing isolated CABG procedure at our institution. We used multivariate generalized estimating equation regression models to adjust for patient mix and subsequently evaluated the effect of both attending cardiac surgeon experience (since fellowship graduation) and the number of previous collaborations between attending cardiac surgeons and cardiothoracic fellow pairs on cardiopulmonary bypass and crossclamp times. RESULTS From 2001 to 2010, 4068 consecutive patients underwent isolated CABG procedure at our institution performed by 11 attending cardiac surgeons and 73 cardiothoracic fellows. Mean attending experience after fellowship graduation was 10.9 ± 8.0 years and mean number of cases between unique pairs of attending cardiac surgeons and cardiothoracic fellows was 10.0 ± 10.0 cases. After patient risk adjustment, both attending surgical experience since fellowship graduation and the number of previous collaborations between attending surgeons and cardiothoracic fellows were significantly associated with a reduction in cardiopulmonary bypass and crossclamp times (P < .001). The influence of attending-fellow pair experience far exceeded the influence of surgical experience with beta estimates for attending-fellow pair experience nearly three times that of attending surgeon experience. CONCLUSIONS Cumulative experience of attending cardiac surgeons and cardiothoracic fellows has a dramatic effect on both cardiopulmonary bypass and crossclamp times, whereas attending cardiac surgeon learning curves following fellowship graduation are clinically insignificant. Taken together, these findings suggest that the primary driver of operative efficiency in CABG procedure is the collaborative experience of the attending surgeon-cardiothoracic fellow operative team, rather than the individual experience of the attending surgeon.

Fascial flap reconstruction of the hand: a single surgeon's 30-year experience.

Background: The reconstruction of complex hand wounds is challenging due to the requirements for thin and pliable coverage with a reliable vascular supply, potential for sensibility, and provision of a gliding surface. Fascial flaps represent an excellent option for the reconstruction of these complicated defects. Methods: A retrospective review of fascial flap reconstructive procedures to the hand undertaken by a single microsurgeon was performed for operations occurring between 1979 and 2009. Both pedicled and free tissue transfer procedures were included in both pediatric and adult patients. Data were culled from a combination of patient charts, hospital records, radiographic studies, and clinical photographs. Results: Sixty fascial flap reconstructive procedures to the hand were analyzed in 60 patients from the defined 30-year period. The most common pathological process necessitating reconstruction was acute trauma (n = 32, 53 percent). Most of the soft-tissue injuries included in the study sample were located on the dorsal hand and wrist (n = 27, 45 percent). The most commonly utilized reconstructive modality was the temporoparietal fascial flap (n = 35, 58 percent). Most reconstructions were completed as free tissue transfers (n = 46, 77 percent). Perioperative complications were relatively minor; no flap losses were recorded. All cases studied demonstrated excellent long-term coverage with no evidence of underlying tendon adhesion or contracture. Conclusion: Fascial flaps represent an excellent option for coverage of soft-tissue defects of the hand that are not amenable to reconstruction with skin grafting alone, particularly for localized defects with denuded tendons or exposed joints.

Body mass index as a predictor of postoperative complications in reduction mammaplasty.

Background: Obesity, determined by body mass index, is known to be associated with surgical complications. This study was performed to evaluate a correlation between body mass index and postoperative complications in reduction mammaplasty. Methods: The authors performed a retrospective analysis of consecutive reduction mammaplasties performed at the Brigham and Womens Hospital by eight surgeons between 1995 and 2007. Data regarding demographics, comorbidities, body mass index, reduction specimen weight, reduction technique, and complications were collected. Univariate and multivariate analyses were used to assess the association between body mass index and complication rates. Multivariate logistic regression analysis was used to determine the threshold body mass index value at which differential complication rates were maximal. Results: A total of 675 bilateral reduction mammaplasties were analyzed; 75 complications (11 percent) were observed, including hematoma, infection, necrosis, and reoperation. Mean body mass index was 31.0 ± 6.2. A significant association was noted between body mass index and complication rate on the basis of both univariate (p = 0.036) and multivariate (p = 0.037) analyses. Trend analysis of body mass index as a categorical variable relative to complication rate was also statistically significant (p = 0.01). A cutoff point was suggested whereby patients with a body mass index of more than 35.6 experienced a significantly higher complication rate than did patients below this threshold (odds ratio = 2.002; p = 0.004). Conclusions: Body mass index is significantly associated with increased complications following reduction mammaplasty. An index value greater than 35.6 is associated with a twofold-higher risk of complications. Patients with a body mass index of 36 or above should be cautioned regarding a potential increased risk of complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

Initial Experience of Dual Maintenance Immunosuppression With Steroid Withdrawal in Vascular Composite Tissue Allotransplantation

Current immunosuppression in VCA is largely based on the experience in solid organ transplantation. It remains unclear if steroids can be reduced safely in VCA recipients. We report on five VCA recipients who were weaned off maintenance steroids after a median of 2 months (mean: 4.8 months, range 2–12 months). Patients were kept subsequently on a low dose, dual maintenance consisting of tacrolimus and mycophenolate mofetil/mycophenloic acid with a mean follow‐up of 43.6 months (median = 40 months, range 34–64 months). Early and late acute rejections responded well to temporarily augmented maintenance, topical immunosuppression, and/or steroid bolus treatment. One late steroid‐resistant acute rejection required treatment with thymoglobulin. All patients have been gradually weaned off steroids subsequent to the treatment of acute rejections. Low levels of tacrolimus (<5 ng/mL) appeared as a risk for acute rejections. Although further experience and a cautious approach are warranted, dual‐steroid free maintenance immunosuppression appears feasible in a series of five VCA recipients.